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Amyloidosis

Amyloid describes various types of protein aggregations that share specific traits when examined microscopically. The name amyloid comes from the early mistaken identification of the substance as starch (amylum in Latin), based on crude iodine-staining techniques. For a period, the scientific community debated whether or not amyloid deposits were fatty deposits or carbohydrate deposits until it was finally resolved that it was neither, but rather a deposition of proteinaceous mass. more...

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To be specific, amyloid deposits are extracellular, thioflavin-positive, and exhibit apple-green birefringence when stained with congo red. Other indicators exist, such as serum amyloid p-component binding. Since these are indirect indicators, biophysicists have redefined amyloid using a canonical set of biophysical characteristics (see below), and this seems to cause a low level of conflict between histologists and biophysicists.

The phenotypes of genetically-transmitted amyloid diseases are often inherited in an autosomal dominant fashion. Sometimes, the difference between aggressive amyloid diseases and senescent amyloid diseases is due to a mutation that makes the protein more prone to aggregation. Most commonly seen are point mutations, which affect the cohesiveness of the protein and promote misfolding; other mutations cause aggregation-prone pieces of the protein to be cleaved off from the rest of the protein.

Diseases featuring amyloid

It should be noted that, in almost all of the organ-specific pathologies, there is significant debate as to whether the amyloid plaques are the causal agent of the disease or instead a symptom downstream of a common ideopathic agent. The associated proteins are indicated in parentheses. Note that amyloidosis by itself ususally refers to AA amyloidosis, but any disease which presents amyloid deposition is technically an amyloidosis. CJD, alzheimer's and diabetes are almost never referred to as amyloidoses.

  • Systemic amyloidosis
    • Primary amyloidosis
      • Mutations in lysozyme, transthyretin, apolipoprotein B, fibrinogen
    • Secondary amyloidosis
      • AA amyloidosis (amyloid A protein, an acute-phase protein due to chronic inflammation)
      • AL amyloidosis (immunoglobulin light chains)
      • Gelsolin amyloidosis (plasma gelsolin fragments).
    • Familial or Hereditary amyloidosis
      • Most commonly caused by mutations in the transthyretin protein, but in rare occurrences can also be caused by apolipoprotein A1, gelsolin, fibrinogen, and lysozyme mutations.
      • Primarily caused by genetics, believed to be autosomal dominant, high probability of passage to offspring
      • Appalachian type amyloidosis
  • Organ-specific amyloidosis
    • Diabetes mellitus type 2 (amylin, also known as IAPP)
    • Neurology
      • Alzheimer's disease (Aβ 39-42)
      • Parkinson's disease (alpha-synuclein) -- biophysical definition
      • Huntington's disease (huntingtin) -- biophysical definition
      • Spongiform encephalopathies
        • Creutzfeldt-Jakob disease (PrP in cerebrum)
        • Kuru (diffuse PrP deposits in brain)
        • Fatal Familial Insomnia (PrP in thalamus)
        • Bovine spongiform encephalopathy (PrP in cerebrum)
      • Congophilic angiopathy (Amyloid beta)
      • congestive heart failure; some instances (PrP in heart)
    • Inclusion body myositis
  • Iatrogenic conditions
    • insulin amyloidosis (injection-administered insulin)

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Localized laryngotracheobronchial amyloidosis:case report and review of the literature
From Ear, Nose & Throat Journal, 9/1/01 by J. Madison Clark

Abstract

Although localized laryngotracheobronchial amyloidosis is rare, the otolaryngologist-head and neck surgeon should be familiar with this condition. Its characteristic appearance can suggest its presence in a patient who has the typical initial symptoms. Biopsies during direct laryngoscopy and bronchoscopy can play both a diagnostic and therapeutic role. After an appropriate examination to rule out systemic involvement, the patient should be managed with conservative surgery, although the use of C[O.sub.2] laser might be more efficacious than conventional surgery. With appropriate diagnosis and treatment, patients should expect a favorable prognosis. In this article, we describe a new case of localized larngotracheobronchial amyloidosis in a 67-year-old woman, and we review the literature on this subject.

Introduction

Localized idiopathic amyloidosis of the respiratory tract is rare. It manifests clinically either in the upper respiratory tract (usually in the supraglottic larynx) or in the lower respiratory tract (usually with tracheobronchial involvement). The occurrence of localized amyloidosis that involves both the upper and lower respiratory tracts is very unusual.

We describe a new case of localized laryngotracheobronchial amyloidosis. To date, the literature contains only a few scattered case reports and a few cases mentioned in reviews of amyloidosis localized to either the upper or lower respiratory tract. A review of the world literature over the past 100 years identified a total of 29 previously reported cases (table 1). (1-8) We have reviewed these cases and we present our conclusions regarding the initial symptoms, diagnosis, and management of this unusual disorder.

From the Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston (Dr. Clark), and the Department of Otolaryngology-Head and Neck Surgery, University of North Carolina School of Medicine, Chapel Hill (Dr. Weissler).

Reprint requests: J. Madison Clark, MD, Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, P.O. Box 250582, 150 Ashley Ave., Charleston, SC 29425. Phone: (843) 792-7165; fax (843) 792-0546; e-mail: clarkm@musc.edu

Case report

A white 67-year-old woman was referred to the University of North Carolina Hospitals for further evaluation and management of a subglottic mass that had been discovered by the referring otolaryngologist during diagnostic direct laryngoscopy. The patient had been seen in consultation with a pulmonologist, who had sought assistance in the management of recalcitrant asthma, for which the patient had been hospitalized for 1 month.

On arrival, the woman reported a several-year history of intermittent hoarseness and frequent wheezing with dyspnea, which had been poorly controlled by bronchodilator inhalation. She denied cough, stridor, and hemoptysis. Her medical history was significant for tobacco abuse (80 pack-years), emphysema, hypertension, eczema, and panic disorder. Her initial physical examination was significant for a coarse, raspy voice, an absence of stridor, normal findings on oral cavity and oropharyngeal examination, and an anteriorly based, sessile, mucosa-covered subglottic mass. Both the appearance of her vocal folds and their motion on flexible fiberoptic laryngoscopy were normal. The results of her blood, chemistry, liver function, and urine tests were normal, as was her acetylcholinesterase level. Assays for human immunodeficiency virus and antineutrophil cytoplasmic antibodies were negative. Her rapid plasma reagin was nonreactive. Computed tomography (CT) of the neck and chest detected emphysematous changes, but no laryngeal, tracheal, or bronchial lesions.

The patient was taken to the operating room, where direct laryngoscopy and bronchoscopy were performed. These investigations revealed the presence of a sessile, mucosa-covered mass with a submucosal yellowish waxy appearance in the left anterior subglottis (figure 1). The mass had caused a 30% stenosis at the level of the subglottis. Two similar but smaller lesions were identified in the cervical trachea, and the right lower lobe bronchus was partially occluded by yet another similarly appearing lesion. Multiple biopsies were taken without complication. A review of pathology confirmed the diagnosis of amyloidosis (figure 2). Specific immunohistochemical staining for the AL subtype of amyloid protein was found in the deposits.

Three years later, the patient has remained stable and has required no further hospitalization or bronchoscopic procedures.

[FIGURES 1-2 OMITTED]

Discussion

The term amyloidosis covers a diverse collection of diseases that manifest by the extracellular deposition of fibrillar amyloid protein. Amyloid deposits occur in many tissues (e.g., the skin, kidneys, heart, and brain) as well as in a variety of locations in the head and neck, including the eye and the major and minor salivary glands. Moreover, submucosal deposits can appear in the nose, paranasal sinuses, nasopharynx, oral cavity, oropharynx, larynx, tracheobronchial tree, and lung.

The most common site of involvement in the upper respiratory tract is the larynx, and the most common sites within the larynx are the false vocal folds. (7) The larynx can also be the first site of involvement in systemic amyloidosis, although laryngeal involvement is less common in systemic amyloidosis than it is in localized disease.

Amyloidosis localized to the lower respiratory tract is classified according to its bronchoscopic appearance as either tracheobronchial or parenchymal. (9) The tracheobronchial pattern is further categorized as either diffuse (more common) or localized (tumor-like masses). The parenchymal pattern is subcategorized as either diffuse or nodular (more common). Although localized amyloid depositions in both the upper and lower respiratory tracts have been reported, this combination is very uncommon. (8)

Our review of the literature reveals that most patients with localized laryngotracheobronchial amyloidosis are Caucasian and that most of these cases occur beyond the age of 40 years (table 1). Initial symptoms typically include hoarseness, cough, and/or dyspnea. The usual upper respiratory (laryngeal) location is the supraglottis, while the usual lower respiratory tract pattern is tracheobronchial. Because examination of the subglottis and lower respiratory tract by flexible fiberoptic laryngoscopy is inadequate, most patients require direct laryngoscopy and bronchoscopy.

In the older literature particularly, amyloid lesions were occasionally confused with tuberculomas and syphilitic gummas; they have also been mistaken for vocal fold polyps and other benign and malignant tumors. However, most authors agree that these lesions have a fairly typical appearance; they generally appear as sessile, mucosacovered masses with a yellowish waxy surface, as was the case with our patient, (10) Given this characteristic appearance, it is reasonable for the surgeon who is considering this disease in the differential diagnosis to take liberal biopsies of these lesions in a therapeutic effort to decrease the resistance to flow in the airways. Of course, the initial endoscopy is primarily diagnostic, and tissue must be sent for pathologic interpretation. Light microscopy will demonstrate glassy eosinophilic material in the submucosa and the classic apple-green birefringence on Congo red staining under a polarizing lens.

The current classification system for the entire group of amyloid diseases is based on the determination of the subunit protein by immunohistochemical staining (table 2). To date, at least 18 different human amyloid fibril proteins have been identified. (11) Primary systemic amyloidosis and localized upper and lower respiratory amyloidosis are made up of AL-type polypeptide light chains of the kappa or lambda (more common) variety. (7)

Determining whether amyloid deposits represent: localized or systemic amyloidosis is crucial, because patients who have the systemic form have a markedly shorter life expectancy. (12) The 5-year survival rate for these patients is less than 20%; it is even lower among those who have cardiac or renal involvement. (13)

The examination to determine the presence of systemic amyloidosis is summarized in table 3. Once the determination is made that the lesion represents localized amyloidosis, certain management conclusions can be drawn from a review of the limited number of cases reported thus far in the literature (table 1).

Management of combined upper and lower respiratory tract amyloidosis is strictly surgical. Although one report described the use of steroids in combination with surgical treatment, (14) most authors agree that neither steroids nor radiation therapy should be used in the management of localized laryngotracheobronchial amyloidosis. (10, 15) In fact, treatments that compromise the immune response--steroids, immunosuppressive chemotherapeutic agents, and ionizing radiation--might even accelerate the process. (16)

The goal of treatment is to remove as much of the grossly visible amyloid as possible without sacrificing normal tissue. A complete "oncologic" resection is rarely achieved. Overzealous resection can result in perforation of a bronchus or severe hemoptysis. (17) Some reports on management of laryngotracheobronchial amyloidosis have suggested that there are clinical advantages to the use of C[O.sub.2] laser surgery. (18) Compared with conventional surgery, laser therapy might be more precise, might cause less inflammation and scarring, and might result in more rapid healing.

References

(1.) Glockner A. Uber lokales tumorformiges amyloid des larynx, der; trachea und der grossen bronchien mitdadurch bedingten laryngotracheostenose. Virchows Arch F Pathol Anat 1900:583-602.

(2.) Herxheimer G. Uber multiple amyloidtumoren des kehlkopfs und der lungs. Virchows Arch F Pathol Anat 1903:130-62.

(3.) New GB. Amyloid tumors of the upper air passages. Laryngoscope 1919;29:327-41.

(4.) McAlpine JC, Fuller AP. Localized laryngeal amyloidosis: A report of a case with a review of the literature. J Laryngol Otol 1964;78:296-314.

(5.) Michaels L, Hyams VJ. Amyloid in localised deposits and plasmacytomas of the respiratory tract. J Pathol 1979;128:29-38.

(6.) Simpson GT II, Strong MS, Skinner M, Cohen AS. Localized amyloidosis of the head and neck and upper aerodigestive and lower respiratory tracts. Ann Otol Rhinol Laryngol 1984:93: 374-9.

(7.) Lewis JE, Olsen KD, Kurtin PJ, Kyle RA. Laryngeal amyloidosis: A clinicopathologic and immunohistochemical review. Otolaryngol Head Neck Surg 1992; 106: 372-7.

(8.) Schulz C, Hauck RW, Nathrath WB, et al. Combined amyloidosis of the upper and lower respiratory tract. Respiration 1995;62: 163-6.

(9.) Hui AN, Koss MN, Hochholzer L Wehunt WD. Amyloidosis presenting in the lower respiratory tract. Clinicopathologic, radiologic, immunohistochemical, and histochemical studies on 48 cases. Arch Pathol Lab Med 1986;110:212-8.

(10.) Mitrani M, Biller HF. Laryngeal amyloidosis. Laryngoscope 1985;95:1346-7.

(11.) Westermark P. The pathogenesis of amyloidosis: Understanding general principles. Am J Pathol 1998;152:1125-7.

(12.) Kyle RA, Bayrd ED. Amyloidosis: Review of 236 cases. Medicine (Baltimore) 1975;54:271-99.

(13.) Gertz MA, Kyle RA. Primary systemic amyloidosis--a diagnostic primer. Mayo Clin Proc 1989;64:1505-19.

(14.) Nugent AM, Elliott H, McGuigan JA, Varghese G. Pulmonary amyloidosis: Treatment with laser therapy and systemic steroids. Respir Med 1996;90:433-5.

(15.) Rubinow A, Celli BR, Cohen AS, et al. Localized amyloidosis of the lower respiratory tract. Am Rev Respir Dis 1978; 118:603-11.

(16.) Friedman I. Nose, throat and ears. In: Symmers WS, ed. Systemic Pathology. 3rd ed. New York; Edinburgh: Churchill Livingstone, 1987:203-5.

(17.) Thompson PJ, Citron KM. Amyloid and the lower respiratory tract. Thorax 1983;38:84-7.

(18.) Talbot AR. Laryngeal amyloidosis. J Laryngol Otol 1990;104: 147-9.

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